Clin Nephrol
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Appropriate antimicrobial therapy poses one of the greatest challenges during the management of a septic patient in the intensive care unit (ICU). Acute renal failure (ARF) is a common complication of sepsis and often occurs as a component of multiple organ dysfunction syndrome. Continuous renal replacement therapy (CRRT) is increasingly used as an effective extracorporeal blood purification therapy in this critically ill patient population. ⋯ Guidelines for antimicrobial prescription which will fit the individual patient undergoing a particular method of treatment are still unavailable. Understanding the principles of drug removal by CRRT and pharmacokinetics of various agents can help to modify the drug dosage and dosing intervals for individualized therapy. Meanwhile, monitoring the drug serum concentration is still mandatory whenever clinically feasible.
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Sepsis continues to provide a major challenge to clinicians. Despite vast advancements achieved in the understanding of its pathways and mechanisms, the incidence of sepsis is increasing and the mortality and morbidity rates remain high, generating a considerable burden to health budgets worldwide. Unfortunately, no definitive therapy yet exists that can successfully treat sepsis and its complications. ⋯ We will also review the importance of treatment dose during continuous renal replacement therapy as a major factor affecting survival in critically ill patients with acute renal failure. We will also review novel information related to other blood purification techniques using largo pore membranes or plasma filtration with adsorbent perfusion. Although these approaches are still in the early stages of clinical testing, they are conceptually promising and might represent an important advance.
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Cardiovascular complications are a major clinical problem in patients with chronic kidney disease and end stage renal failure. Death from cardiac causes accounts for 40%-50% of all deaths in these patients and is thus up to 20 times more common in uremic patients than in the general population. Cardiovascular pathology in patients with renal failure is complex, but accelerated atherosclerosis has repeatedly been discussed as one major cause. ⋯ These changes in vascular wall composition may alter vessel elasticity and thus contribute to impaired vessel function in renal failure. It is obvious from the above mentioned facts that cardiovascular disease in the renal patient is certainly multifaetorial in origin. There are, however, important issues to adress in the future, like (I) the characterization of vascular morphology in the different vascular beds, (II) the pathomechanisms of vascular and plaque calcification as well as the potential beneficial effect of rigorous control of non-classical risk factors (i.e. high P or Ca x P, inflammation, oxidative stress, etc.), (III) an additive or supraadditive effect of various classical and non-classical risk factors and (IV) the role of diabetes mellitus in modifying these vascular alterations.
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Review Case Reports Comparative Study
Alkalinization and hemodialysis in severe salicylate poisoning: comparison of elimination techniques in the same patient.
We report the case of a man who took two overdoses of aspirin, on each occasion suffering a grand mal fit with blood levels of salicylate of over 5 mmol/l. The first event was treated with hemodialysis but without effective alkalinization, and the second with alkalinization but without hemodialysis. ⋯ Similar salicylate levels were achieved with both techniques by 24 hours post-overdose. If a case of salicylate poisoning is to be treated with hemodialysis, treatment with alkalinization should still be given without delay, in order to prevent acidemia and to promote elimination of as much salicylate as possible via the kidneys.
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Review Comparative Study
Acetate free biofiltration (AFB): from theory to clinical results.
Acetate free biofiltration (AFB) is a hemodiafiltration technique based on a buffer-free dialysate and bicarbonate infusion in the postdilution mode. The performance of AFB requires a dialysis machine equipped with an automatic control system to balance the infusion rate to that of ultrafiltration. The filters employed are usually polyacrylonitrile hollow-fiber hemodialyzers. ⋯ However, it is not known whether these positive effects may entail better long-term prognosis; moreover, comparisons between AFB and conventional dialysis were never designed to ascertain the role of the dialysis membrane from that of the other components of AFB on clinical results. Therefore, large prospective trials with long observation periods are necessary to clarify the mechanisms through which AFB might be superior to conventional dialysis as well as the impact of these techniques on long-term prognosis. In such studies other relevant factors such as rehabilitation and life quality of the patients, which have been generally neglected in previous surveys, must also be included to evaluate cost-effectiveness of this therapy.